The Certification by Insurance Broker or Agent form is a required document in New York City that verifies the accuracy of an attached Certificate of Insurance. Insurance brokers and agents use this form to declare that all information is correct in every material respect. The form collects the broker’s full identification, including typewritten name, address, email, and phone or fax number. A Notary Public must witness and notarize the declaration, adding official seals and a signature. This notarization step protects all parties involved and confirms the legal standing of the certification. The form is widely used in commercial and professional settings across NYC to maintain trust between city agencies and insurance professionals.
| Question | Answer |
|---|---|
| Form Name | Certification Broker Form |
| Full Title | Certification by Insurance Broker or Agent |
| Issuing Authority | City of New York |
| Form Length | 1 page |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Notarization Required | Yes |
| Other names | certification insurance broker agent, certification broker agent, certification broker nyc form, broker state york |